Angie Stewart:
Hello, and welcome to Healthcare Insider, a sponsored content podcast series from Modern Healthcare Custom Media. I'm your host, Angie Stewart, and today we are thrilled to welcome to the podcast Dr. Jody Crane, Chief Medical Officer of Team Health. Dr. Crane is considered a leading expert of emergency department operations in the US with experience helping hundreds of organizations across six continents. In his role at Team Health, Dr. Crane supports quality and safety and performance improvement initiatives for all clinical service lines. In addition to his leadership role at the company, he is a practicing emergency medicine physician. In today's episode, Dr. Crane will be sharing his perspective on the major issues impacting emergency departments today and explain solutions that will improve efficiency, clinical quality, and patient experience. Dr. Crane, thanks so much for being here today.
Jody Crane:
Well, thanks Angie, and I really appreciate the invitation to speak to Modern Healthcare today.
Angie Stewart:
I'm excited to dive in. So my first question is, what are some of the key challenges that emergency department leaders currently face in providing frontline care?
Jody Crane:
Angie, the challenges today are not too different from the challenges prepandemic, they're just a lot more pervasive than they were before. And I think the most important challenge facing ED leaders right now today is overcrowding in the hospital, which is driving boarding and the lack of resources like nurses and beds to care for patients in the emergency department. These post pandemic workforce shortages are not limited to physicians and nurses, but we're also seeing workforce shortages and ancillary services pretty much across the hospital. So the overcrowding is driving patients to board in the emergency department consuming beds, consuming nurses, but then we have this layered on effect, which we'll talk about in a little bit related to just being able to get the other tests done in the hospital. This is really resulting in this burnout or this moral injury that you hear about all the time.
The way I look at it is your job is to save lives, and you're driving into work shift after shift, but on your drive, you understand you're probably not going to have the resources you need to get the job done. And that's different than a plumber not having a wrench. This is life-saving care, and you're going, "Well, wait a second, I'm having to care for this person in atrial fibrillation, but I'm in the waiting room and I'm calling consults from the waiting room." And this is also this layered effect of reimbursement challenges that we're seeing.
So I'm sure a lot of people are aware of this, but Medicare, Medicaid has been gradually reducing payments in a very intended way, but also in some ways where they might not have intended to, like the 2023 CPT changes or the coding changes released by AMA have actually reduced payments to emergency physicians and hospital physicians and had these unintended consequences because of the way that the new CPT guidelines are structured. You layer on managed care payers denying payments, and this whole surprise medical billing legislation that we feel pretty strongly was flawed in its implementation to heavily favor payers. And so what has been going on is that we've had to pay $350 to try to get fair reimbursement for chasing a bill that's maybe only worth $300. So I don't know that it made sense up until today. The good news is the government has passed some changes in that legislation to reduce the fees for surprise medical billing.
Things are slowly working back, but it's a real struggle when you get through the pandemic, you're going into work wondering if you're exposing yourself to potentially a lethal virus or bringing it home to your family, and then all along the people that determine reimbursement rates are telling you you're just not worthy of what we were paying you before. So although our jobs are more stressful, higher acuity patients, much more difficult working environments, but the people that are determining reimbursements are telling us that we're not worth it. And that's what emergency physicians and other staff members in emergency departments are feeling right now. So it's just layered on, we don't necessarily have the tools to do our jobs and people are telling us that we're not valued as much as perhaps we were before. I know that's kind of heavy, but I do feel like that's the sentiment out there.
Angie Stewart:
Absolutely. From overcrowding to the reimbursement constraints, it sounds like there are a lot of really serious challenges. So what workforce issues specifically are affecting emergency departments, and what solutions can be introduced to address the issues?
Jody Crane:
It's interesting, and I'm glad you asked that question because if you think about it, the pandemic came across and had a really catastrophic impact on volumes on at least hospital-based volumes, but pretty much physician practices across the country were closing shop basically, cancel elective surgeries and just really having a challenge getting volume in the door. So every wave that came through of the pandemic COVID would spike and then we would see this sheltering in place and people wouldn't come into the emergency department even for serious conditions. So what's happened is we've had to adjust schedules, up staff, down staff trying to chase these volumes, and then on top of that, coming out of the pandemic with the workforce, this impact on the workforce where people are burnt out and they're either reducing hours or going into other more predictable work environments. For those that have stayed, like I mentioned before, it's more difficult.
And this has resulted in this workforce shortage that we've seen now that really we haven't seen in decades. We have the most challenging workforce problem today than we've ever had before. So like I said, early on during the pandemic, we were trying to chase these waves that maybe lasted two or three months in duration. So COVID spike would hit, and you'd see people shelter in place and we'd have to reduce staffing in order to not have people sitting around and being exposed to COVID and potentially getting sick or to make ends meet financially in physician practices. And so what's happened is the ability to respond to those two to three month windows, if you think about it, how do you staff up for something that you don't know how long it's going to last? And then when it goes away, how do you staff back down, and how do you do all that in a way that makes sense to the average physician or nurse or other ancillary staff out there?
And so the problem is if you didn't do this right, it threatened the very viability of physician groups. And we've heard recently in the last six months, two major physician staffing companies that have gone under, literally have gone bankrupt. And two of the major things that they cited were effects of COVID and impact on volumes and then these managed care insults that we've talked about before. So over time, physicians, nurses and other staff just got frustrated with the constantly changing schedules and the episodic changes in demand. So the good news is, I think on that note is that the variation demand that we've seen from the pandemic is starting to fade as COVID goes into indemnity. And what that means is we're going to start seeing these traditional seasonal patterns even with things like flu and RSV. They may have a COVID component to them.
So right now, we just got over a small COVID wave, but influenza and RSV haven't even kicked into full gear yet. So we saw a little bit of bump in volumes recently, but the point is those fluctuations are going to start to level out, and we'll get back to prepandemic predictability in terms of volumes, and then we won't have to adjust schedules as much as we did previously. And so, again, it's been very, very tough managing this incredible variation that we've seen. But we do believe that this is getting better and we believe that as nurses return and as we get a more stable workforce that things like caring for patients in the waiting room won't be a regular thing like it is today because we'll have more capacity up in the hospital, and we'll have more capacity in the emergency department.
Angie Stewart:
Right. It's really interesting to think about the variations in patient volumes that we've seen. Another thing that's been a moving target coming out of the pandemic is patient experience. What are some things emergency department leaders can do to maintain or improve patient experience?
Jody Crane:
Well, that's a loaded question, I think, but I appreciate Angie because it's important. People that work in emergency department, as we started to come out of the pandemic, everybody got back business as usual, which was, "Hey, let's start focusing on our metrics like door to doctor times, like left without being seen rates, like patient experience." But the thing that we didn't anticipate was this pandemic after the pandemic, this workforce issue of people that were just exhausted. And if you think about it, when COVID came around, we were in fear of our lives. So people had a very different guttural response to the pandemic, but now after the pandemic, we're facing this other piece of it, which is we're just burnt out from working so much and so hard in high acuity environments. At the same time, we realize that we've got to get back to the basics.
We've got to start measuring things that matter both to patients but also to clinicians and to organizations. So like I mentioned, door to doc times, left without being seen rates, patient experience. I think all of that is coming back, but it maybe came back a little bit fast for people to digest. But I will say that what our team has seen, so at TeamHealth, we have a patient experience team that goes around and really educates on patient experience. And our team began to realize very early on in this return to managing of the metrics that emergency department teams were less receptive to patient experience training. And the whole goal of satisfying patients, you might think, "Well, how can that be? These are caring, loving individuals that got into this to take care of patients." But what we frequently heard was, "I'm less concerned about patient experience, I'm concerned about my own experience, and I'm having trouble just showing up to work because I'm just fried."
So we had to rethink the way we approach these teams, but also the basics are the basics, right? We tailored our efforts to this new reality, and we decided that we've always had this view, and it's definitely true in the emergency department, that timeliness of care and the process being patient oriented matters. So what Press Ganey will tell you is if patients are in the emergency department for less than two hours total, they uniformly have very high patient experience scores. So we know that front end and getting patients in front of clinicians and nurses matters, but also getting them along in their journey as quickly and reliably as possible is a big piece of it. So we doubled down on that. And I do think there's been some frustration around that because, again, we're treating people in the waiting room.
We don't even have beds for patients, but we believe very strongly that any patient that walks into the emergency department should be seen in a timely manner to make sure that they're safe, their psychological concerns are addressed, and we can get them on their way into their journey to getting better. So there's that flow piece of it that we've literally doubled down on, and I think you can't exist without it when you're caring for so many patients in the waiting room. And then just reiterating or reemphasizing the fact that satisfied patients actually drive provider and clinician satisfaction. So nurses, docs, everybody that works in the emergency department, when you see a patient flawlessly and get a wow and a thank you from a patient, it does change that drive into the emergency department. And when you're expecting to get wows from every patient as opposed to getting a mouthful from a patient that's been waiting in the waiting room for five hours, it really does matter.
So happy patients make happy clinicians. Satisfied patients are more likely to follow up on treatment, they're more likely to have better quality outcomes, and they're much less likely to sue their caregivers. So we continue to appeal to the things that matter to clinicians, but it's still more difficult than it was prepandemic in the context of all of these struggles that we've been facing.
Angie Stewart:
Really interesting points. It's fascinating the balance of patient experience with clinician experience and how those two are linked together. What action items or strategies can emergency department leaders implement to improve both efficiencies and clinical quality in their department?
Jody Crane:
So, Angie, great question. And again, if you think about all the stuff that we've talked about so far, the challenges just coming into work and the flow problems and the nursing resource limitations, et cetera, it's almost inconceivable to think about trying to improve things when you're just trying to get by. I will say the things that we believe work right now and are time tested, number one, I think the most important strategy is to have a collaborative mindset, both at the ED leadership perspective, but also with respect to frontline care delivery. And what that means is typically physicians and nurses will work in silos. So the docs will make their schedule, the nurses will make their schedule, and the people just show up to work, and they work in what I sometimes call this black box. You show up, you man your team, you work with whatever doctors around, and you just get through patients.
And our philosophy is not only do you need to have a collaborative mindset at the leadership level where you're designing systems that are integrated with respect to not only nurses and docs but also ancillary teams and how they fit into the overall process, but then also your care delivery model. I talked about front-end models. They have to be well-designed, and we have to know what kind of clinician do we want out there? Do we want a doctor? Do we want a nurse practitioner or a PA? How many nurses? Do we need a phlebotomist out there? Do we need some transporter to get patients to and from x-ray and CT? So we have to have this team-based mindset, and we have to, again, fall back on that, get every patient seen so nobody's at risk in the waiting room and get them moving along in their process.
So that combination of leadership, collaboration, and then designing processes that have a team-based mentality I think is critical to the future success of emergency departments. And it works in any setting, but even more so applicable right now. The other part of that is when you design systems like this, you need to understand and really closely monitor the data to understand when you need to re-adapt or reassess your model. So you might set in a front end model that's designed to handle four patients per hour. Next thing you know, six patients per hour are coming in because people are thrilled with the care that your emergency department's giving. Well, your four patient per hour model is not going to work in the six patient per hour volume. So you've got to constantly reassess, readapt. And, again, just like we talked about patient experience, well-designed systems can improve quality, flow, reduce risk, and have a massive impact on patient experience.
Early on in my career, I was exploring these front end models, and I can't tell you the change that it had on my life. I would walk into my emergency department just fully expecting to get yelled at all night on my night shift, every patient waiting over 12 hours to be seen, and I'm just taking it and then started exploring front end models and realized people are saying, "Wow, you saw me within five minutes of coming through the door." And, oh, by the way, every once in a while you pick up a heart attack that would've been sent back out to the waiting room or a stroke patient that would've been sent back out to the waiting room.
I actually had this one case where a lady came in and she had Bell's palsy, facial droop. She was in her mid 40s, and she thought for sure she was having a stroke. And I pulled her right out of triage and saw her right behind triage very early. We didn't have a process. I was just fiddling around up there. And I just explained to her that I think you have Bell's Palsy, need to do some workup, but I think everything's going to be fine. And she got her workup done, everything was fine, sent her home. The CEO of the hospital called me the next day, and he said, "Hey, I just want to let you know I got a phone call from a lady you saw in the emergency department."
Now sometimes that's not good news, but he said, "I just want to let you know she was thrilled with the care, but the most important part of your visit with her was the fact that you saw her within five minutes and you told her she wasn't having a stroke." And she was thrilled with all of the care afterwards, but that was the most important thing for that person. And I think we need to really be mindful of that fact that at the end of the day, caring for patients in the emergency department is just that, it's caring for patients, and it's people caring for other people. The diagnostics and all of that suffer just part of the equation if you get those wrong problem. But the most important thing is understanding what the patient needs and addressing it.
And just two more bullets I think that are important in terms of actions or strategies that we need to employ across the United States, and I'll highlight this next one by quoting an article from Donald Chalfin and a friend of mine Steve Trzeciak in Critical Care Medicine. And this article is 15 years old, but it showed that patients with greater than a six hour delay between the time they get admitted from the emergency department until the time they go up to the ICU have a one day longer length of stay in the hospital and they have a 30% increase of mortality.
So if you think about that, delays in the emergency department in admission, so crowding, actually causes sort of a self-fulfilling prophecy that they're going to be in the hospital longer, which is going to further congest the hospital. And what I always say when I'm talking to hospital systems out there and convincing them to work on crowding is boarding kills. And this is a great example. Boarding increases mortality 30%. And so if that's not enough to get you working on hospital overcrowding, I don't know what else is. But in this light, the second strategy is to have a system-wide approach to overcrowding and boarding. And this has to be led by the C-suite, and creativity and accountability is the key. And there's lots of strategies out there. One of my favorites is IHIs real-time capacity management system, which is a systematized approach to admitting patients and understanding how to get them discharged reliably.
There's another one called the Full Capacity Protocol by Peter Viccellio, which allows us to send patients upstairs into the hallway when boarding in the emergency department reaches a critical limit. And then Eugene Litvac has a program about OR smoothing, and what he's shown, is you can free up hospital beds by just smoothing the OR schedule across the five days of the weekday. And so there's lots of strategies out there. The most important concept in all of the overcrowding improvement work is it's got to be led by the C-suite, and C-suite has to hold people accountable all the way down to the front lines. And what I typically will coach health systems to do is just treat the boarding and the dispo to admit time in the emergency department like the queue for the hospital. And your goal is to own that queue just like the emergency department's goal is to own the queue of patients walking in the front door to eliminate left without being seens.
And I guess the final recommendation would be for us to really focus on the wellness of our caregivers. And it seems self-evident, but it's actually much harder to execute on than you would think. Burnout and stress are at all time highs and so is depression and suicide risk. And so we are seeing higher levels of depression and suicide than we've ever seen before in healthcare. And it's all of the stuff that we've talked about throughout the podcast. We've got to do whatever it takes to support clinicians. In particular, I love the work by the Lorna Breen Foundation, which they're driving. Lorna Breen was an emergency physician that got COVID in the middle of the pandemic, and she went home, recovered, went back to work, but wasn't feeling right mentally. And she was worried that if she reported that and sought help that she would lose her license and lose her ability to practice.
And she ended up committing suicide. The Lorna Breen Foundation is out there basically changing laws at the state level and advocating at the federal level for clinicians and all healthcare workers to be able to access mental healthcare without fear of retribution or losing licenses or anything like that. I think that's part of it, is to be open and remove the stigma around mental health challenges because I tell you it's the hardest work environment that we've ever had to be in right now, and things that we can do to underscore work-life balance to make the stuff I talked about, scheduling and constant changes in the schedule, if we can minimize that, it's going to allow our clinicians and our nurses and other folks in healthcare to have a better work-life balance and have a more predictable vacation schedule, et cetera. We've got to wind it back to times where people really were able to find joy in work, and however we can do that, we've got to double down on that emphasis.
Angie Stewart:
Exactly. ED physicians are up against a lot, as you said, some of the hardest challenges the profession has seen. I really appreciate the models and resources that you shared as well as the strategies and insights from your own experience that can really help organizational leaders make a difference with this issue. Dr. Crane, thank you so much for being here today.
Jody Crane:
Well, Angie, thank you so much for inviting me and a big fan of mine in healthcare. So thanks for all you guys are doing to help promote all of this type of stuff out there and everything you're doing on behalf of physicians and healthcare workers nationally,
Angie Stewart:
Thank you so much. This has been a sponsored episode of Healthcare Insider created in collaboration with Team Health. For more information, please visit team health.com/services. I'm your host, Angie Stewart. Look for more episodes of Healthcare Insider under the multimedia tab at modernhealthcare.com or subscribe to your preferred podcatcher. Thanks for listening.
